Impact of the COVID-19 Pandemic on Blood Lead Testing in Children in the United States.

The study objective was to evaluate the impact of the coronavirus disease (COVID-19) pandemic on pediatric blood lead testing in the United States. Clinical laboratory pediatric (ages <6 years) blood lead level (BLL) tests performed by Quest Diagnostics, January 2019-March 2022, were analyzed. Patients were categorized by age, by sex, and, through matching by ZIP code with US Census data, for race, ethnicity, pre-1950 housing, and poverty estimates. Over 2.8 million results from children (<6 years old) from all 50 states and the District of Columbia were included. Compared to March-May 2019, BLL testing was lower by 53.6% in March-May 2020 and lower by 14.6% in March-May 2021. Testing rebounded more for children in predominantly White non-Hispanic communities and among children living in communities, based on ZIP codes, with the least pre-1950 housing stock and lowest poverty rates. The proportion of children with BLL at or above the United States Centers for Disease Control and Prevention reference values of 3.5 and 5.0 µg/dL fell by 19% and 24%, respectively, in 2021 versus 2019. In conclusion, pediatric BLL testing has rebounded from sharp declines during the early pandemic period but unevenly. Declines in the proportion of children with elevated BLL should be interpreted with caution, as testing rebounds were less robust among communities with the highest risk of lead poisoning, notably communities with the oldest housing stock and higher poverty rates. More public health efforts are needed to address lead toxicity throughout the United States, especially in communities that did not experience a full rebound subsequent to the early COVID-19 pandemic period.

Quantifying lead-attributable cardiovascular disease burden in the United States.

Lead exposure has been linked to a myriad of cardiovascular diseases. Utilizing data from the 2019 Global Burden of Disease Study, we quantified age-standardized lead exposure-related mortality and disability-adjusted life years (DALYs) in the United States between 1990 and 2019. Our analysis revealed a substantial reduction in age-standardized cardiovascular disease (CVD) mortality attributable to lead exposure by 60 % (from 7.4 to 2.9 per 100,000), along with a concurrent decrease in age-standardized CVD DALYs by 66 % (from 143.2 to 48.7 per 100,000).

Effect of Environmental and Socioeconomic Factors on Increased Early Childhood Blood Lead Levels: A Case Study in Chicago.

This study analyzes the prevalence of elevated blood lead levels (BLLs) in children across Chicagoland zip codes from 2019 to 2021, linking them to socioeconomic, environmental, and racial factors. Wilcoxon tests and generalized additive model (GAM) regressions identified economic hardship, reflected in per capita income and unemployment rates, as a significant contributor to increased lead poisoning (LP) rates. Additionally, LP rates correlate with the average age of buildings, particularly post the 1978 lead paint ban, illustrating policy impacts on health outcomes. The study further explores the novel area of land surface temperature (LST) effects on LP, finding that higher nighttime LST, indicative of urban heat island effects, correlates with increased LP. This finding gains additional significance in the context of anthropogenic climate change. When these factors are combined with the ongoing expansion of urban territories, a significant risk exists of escalating LP rates on a global scale. Racial disparity analysis revealed that Black and Hispanic/Latino populations face higher LP rates, primarily due to unemployment and older housing. The study underscores the necessity for targeted public health strategies to address these disparities, emphasizing the need for interventions that cater to the unique challenges of these at-risk communities.

Improving Equitability and Inclusion for Testing and Detection of Lead Poisoning in US Children.

Policy Points Child lead poisoning is associated with socioeconomic inequity and perpetuates health inequality. Methods for testing and detection of child lead poisoning are ill suited to the current demographics and characteristics of the problem. A three-pronged revision of current testing approaches is suggested. Employing the suggested revisions can immediately increase our national capacity for equitable, inclusive testing and detection. ABSTRACT: Child lead poisoning, the longest-standing child public health epidemic in US history, is associated with socioeconomic inequity and perpetuates health inequality. Removing lead from children's environments ("primary prevention") is and must remain the definitive solution for ending child lead poisoning. Until that goal can be realized, protecting children's health necessarily depends on the adequacy of our methods for testing and detection. Current methods for testing and detection, however, are no longer suited to the demographics and magnitude of the problem. We discuss the potential deployment and feasibility of a three-pronged revision of current practices including: 1) acceptance of capillary samples for final determination of lead poisoning, with electronic documentation of "clean" collection methods submitted by workers who complete simple Centers for Disease Control and Prevention-endorsed online training and certification for capillary sample collection; 2) new guidance specifying the analysis of capillary samples by inductively coupled plasma mass spectrometry or graphite furnace atomic absorption spectrometry with documented limit of detection ≤0.2 µg/dL; and 3) adaptive "census tract-specific" universal testing and monitoring guidance for children from birth to 10 years of age. These testing modifications can bring child blood lead level (BLL) testing into homes and communities, immediately increasing our national capacity for inclusive and equitable detection and monitoring of dangerous lower-range BLLs in US children.

Uneven development of the lead industry leads to regional differences in blood lead levels of children.

Children's exposure to lead is a global health problem, especially in low- and middle-income countries. However, research on the relationship between children's blood lead levels (BLLs) and the development of the lead industry is still limited. This study examined whether children's BLLs were associated with the development of lead industry in different regions. Using survey data on the BLLs of children living in 250 prefectures in China with corresponding data on their economic factors and lead industries, we explored the regional variation of children's BLLs using statistical methods. The results show that the level of economic development in leaded areas was associated with inequity in children's BLLs and met the environmental Kuznets hypothesis. In areas without lead industries, there was little correlation between the level of economic development and the BLLs of children and thus the environmental Kuznets hypothesis was not supported. Lead mines, lead smelting and chemical companies are major sources of blood lead in children living in leaded areas. This study demonstrated the success of control policies for lead-acid battery manufacturers in promoting the prevention and control of childhood lead poisoning in China. China should consciously support the improvement of children's BLLs in undeveloped areas with lead industries through national financing and policies to avoid the continuous effects of the regional inequality problem of high children's BLLs.

Environmental assessment of pediatric Lead exposure in Tehran; a prospective cross-sectional study.

BACKGROUND: Ingestion and inhalation are common routes of exposure for lead in humans. Developing countries still have unacceptably high rates of lead toxicity, especially in children. Studies on probable risk factors of lead poisoning in Iranian children are insufficient. In this study, we aimed to evaluate possible environmental factors in children with high blood lead concentrations living in Tehran and neighboring cities. METHODS: In a prospective cross-sectional study between March 2018 and March 2019 we followed all children referred from two pediatric gastrointestinal clinics with blood lead level (BLL) > 5 µg/dL in metropolitan Tehran to investigate possible environmental risk factors in their home. Household specimens including scratched wall paint, house floor dust, windowsill dust, tap water, and consumed spice were evaluated using atomic absorption method to detect lead concentrations. Epidemiological and environmental data collected through in-depth interviews with parents/guardians. Industrial areas were defined based on municipality maps on industrial places. RESULTS: Thirty of 56 parents/guardians with BLL > 5 µg/dL agreed to be followed through environmental investigation. The only categorical statistically significant risk factor was a history of lead poisoning in the family and living in an industrial zone. There was a positive correlation between BLL and interior windowsills dust lead level, r = 0.46, p = 0.01. Scratched paint lead level and BLL showed a significant positive correlation, r = 0.50, p = 0.005. House floor dust lead level (median = 77.4, p < 0.001) and interior windowsill dust lead level (median = 291, p = 0.011) were both significantly higher than the environmental protection agency (EPA) standards of 40 µg/ft2, 250 µg/ft2. Interior windowsill dust lead concentrations were significantly higher in industrial areas (p = 0.026). CONCLUSION: Children's playing environment should be cleaned more often to reduce dust. Moreover, specific rules may need to be implemented for paint lead concentrations and air pollution, especially in industrial areas.

Exploring persistent racial/ethnic disparities in lead exposure among American children aged 1-5 years: results from NHANES 1999-2016.

OBJECTIVE: The aim of this study was to determine whether long-standing racial disparities in lead exposure still exists for children age 1-5 years old. We examined if blood lead levels were higher among non-Hispanic Black children and others compared to non-Hispanic White children. METHODS: Data from the National Health and Nutrition Examination Survey (NHANES) from 1999-2016 were used. Geometric mean blood lead levels (BLLs) were compared by race/ethnicity using log-transformed simple linear regression. Associations between race and elevated BLL were assessed using weighted Chi-square tests. Log-transformed multiple weighted linear regression was used to assess what factors affected BLLs. RESULTS: A total of 6772 children were included in this study. In 1999-2000, the geometric mean BLL for non-Hispanic Black children was 3.08 µg/dL, compared to 2.03 µg/dL for non-Hispanic White children (p = 0.01). The difference in geometric mean BLL between non-Hispanic Black children and non-Hispanic White children continued to be statistically significant in later years (all p < 0.05) until 2015-2016 (0.89 µg/dL vs 0.74 µg/dL, p = 0.17). Log-transformed linear regression showed that being non-Hispanic Black and having low family income were independently associated with higher BLL. CONCLUSION: Although lead exposure in the general population continued to decline for all racial/ethnic groups, non-Hispanic Black children still had higher BLL than non-Hispanic White children. In more recent years, the racial/ethnic gap was lesser but persisted. Racial/ethnic disparity in childhood BLL could be partially explained by socio-economic factors.

Assessing the population-wide exposure to lead pollution in Kabwe, Zambia: an econometric estimation based on survey data.

This study quantitatively assessed the population-wide lead poisoning conditions in Kabwe, Zambia, a town with severe lead pollution. While existing data have reported concerning blood lead levels (BLLs) of residents in pollution hotspots, the data representing the entire population are lacking. Further, selection bias is a concern. Given the lack of compulsory testing schemes, BLLs have been observed from voluntary participants in blood sampling surveys, but such data can represent higher or lower BLLs than the population average because of factors simultaneously affecting participation and BLLs. To illustrate the lead poisoning conditions of the population, we expanded the focus of our surveys and then econometrically estimated the BLLs of individuals representing the population, including those not participating in blood sampling, using background geographic, demographic, and socioeconomic information. The estimated population mean BLL was 11.9 µg/dL (11.6-12.1, 95% CI), lower than existing data because of our wide focus and correction of selection bias. However, the scale of lead poisoning remained immense and 74.9% of residents had BLLs greater than 5 µg/dL, the standard reference level for lead poisoning. Our estimates provide a deeper understanding of the problem and a foundation for policy intervention designs.

Lead poisoning risk assessment of radiology workers using lead shields.

Purpose: Lead containing dust may be present on the exterior surfaces of shields used to prevent radiation exposure. We determined whether use of lead shields poses an exposure risk for radiology personnel.Methods: We collected hand dustwipe and blood samples from 58 Radiology Department employees of an academic hospital. Samples were analyzed for lead content by atomic absorption spectroscopy. Results were compared between lead apron users (46) and nonusers (12).Results: Hand dustwipe lead was undetectable (<3 µg/sample) in all cases. Blood lead levels ranged from 0-3 µg/dL.Conclusions: In this study of Radiology Department workers, we did not find an increased risk of lead contamination on their hands or in their blood. Although our sample size is small, we conclude that lead poisoning is unlikely to occur with high frequency in lead shield users.

Professionals' Perceptions: "Why is Lead Poisoning Prevalent in Lancaster County?"

BACKGROUND: The prevalence of lead poisoning in children under the age of six years living in Lancaster County, Pennsylvania continues to be greater than the state-wide prevalence for this age group. This study aims to determine the factors that contribute to the high lead poisoning rates. METHODS: For this qualitative study, the researchers recruited a convenience sample of professionals providing healthcare and social welfare services in the county. Researchers conducted in-depth interviews with participants. The research team audio recorded, transcribed verbatim, and analyzed each interview using NVivo 12 software. RESULTS: The 16 interviewed participants identified factors that contribute to high lead poisoning rates including knowledge levels, housing status, and competing interests. Specifically, low knowledge levels, renting as opposed to home ownership, and having competing interests seemed to minimize the attention directed towards preventing lead poisoning. The experts offered recommendations to address the high lead poisoning rates including increasing lead knowledge levels of both community members and landlords, through creating and distributing health promotion material, enacting policies to empower renters, and systematically collaborating to streamline lead poisoning related information and services. CONCLUSIONS: Findings provide insights to factors that Lancaster can address to achieve a decrease in lead poisoning rates. This study provides information that can be utilized by public health professionals to develop appropriate interventions.

Environmental injustice and childhood lead exposure in peri-urban (ger) areas of Darkhan and Erdenet, Mongolia.

BACKGROUND: The ger ("tent city") areas in Mongolia are a product of rapid urbanization and transitional economic development combine with lack of institutional, administrative and financial capacity of governments to cope with the pace. These areas have become traps for inequities in social and environmental services and the associated effects on human health. Disparities in childhood lead exposure in such communities are largely unexplored. METHODS: We measured the concentrations of lead in blood of children, aged 4-7 years, in Erdenet (Orkhon Province) and Darkhan (Darkhan-Uul Province), the second and third largest cities in Mongolia. A survey instrument was used to gather information on influencing factors on lead exposure and the Strengths and Difficulties Questionnaire (SDQ) was used to assess a spectrum of behavioral problems among the children. RESULTS: The mean blood lead level (BLL) of children in the two cities was found to be 3.8 ± 2.6 µg/dL (range: < 1.5-17.2 µg/dL) and 27.8% of the children had BLLs ≥5 µg/dL. Average BLL of children in Erdenet (a mining center) was significantly higher than that for children in Darkhan, and there was statistically significant difference between average BLL of children who live in ger district (4.2 ± 2.8 µg/dL) compared to those of children in housing units within the city (3.2 ± 2.4 µg/dL). In spite of the low values, BLLs was significantly associated with a number of effects on the spectrum of behavioral disorders, specifically with the scores for hyperactivity, conduct disorder and pro-social behavior. CONCLUSIONS: This study shows that childhood lead poisoning is common especially in ger communities of the urban areas of Mongolia. It contributes evidence showing that BLL low as 3.8 µg/dL can selectively activate some effects from a spectrum of likely behavioral disorders in children.

Assessment of the prevalence of lead-based paint exposure risk in Jakarta, Indonesia.

While lead-based paint has been banned for use in residential settings in most high-income countries, it remains commonly available in many low- and middle-income countries (LMICs). Despite its continued availability, little is known about the specific exposure risk posed by lead-based paint in LMICs. To address this knowledge gap, an assessment of home and preschool dust and paint was carried out in Greater Jakarta, Indonesia. A team of investigators used field portable X-ray Fluorescence (pXRF) to measure 1574 painted surfaces for the presence of lead (mg/cm2) and collected 222 surface dust wipe samples for lead loading (µg/m2) from 103 homes and 19 preschools across 13 different neighborhoods of Jakarta. The assessment found that 2.7% (n = 42) of pXRF measurements and 0.05% (n = 1) of dust wipe samples exceeded the commonly applied USEPA guideline values for paint (1 mg/cm2) and dust (floors: 431 µg/m2; window sills: 2691 µg/m2). Thus, contrary to expectations the locations analyzed in Greater Jakarta showed that exposure risk to lead-based paint appears low. Further study is required in other settings to confirm the findings here. Precautionary measures, such as the proposed ban on lead-based paint, should be taken to prevent the significant social and economic costs associated with lead exposure.

Assessment of Child Lead Exposure in a Philadelphia Community, 2014.

INTRODUCTION: Several urban neighborhoods in Philadelphia, Pennsylvania, have a history of soil, household lead paint, and potential lead-emitting industry contamination. OBJECTIVES: To (1) describe blood lead levels (BLLs) in target neighborhoods, (2) identify risk factors and sources of lead exposure, (3) describe household environmental lead levels, and (4) compare results with existing data. METHODS: A simple, random, cross-sectional sampling strategy was used to enroll children 8 years or younger living in selected Philadelphia neighborhoods with a history of lead-emitting industry during July 2014. Geometric mean of child BLLs and prevalence of BLLs of 5 µg/dL or more were calculated. Linear and logistic regression analyses were used to ascertain risk factors for elevated BLLs. RESULTS: Among 104 children tested for blood lead, 13 (12.4%; 95% confidence interval [CI], 7.5-20.2) had BLLs of 5 µg/dL or more. The geometric mean BLL was 2.0 µg/dL (95% CI, 1.7-2.3 µg/dL). Higher geometric mean BLLs were significantly associated with front door entryway dust lead content, residence built prior to 1900, and a child currently or ever receiving Medicaid. Seventy-one percent of households exceeded the screening level for soil, 25% had an elevated front door floor dust lead level, 28% had an elevated child play area floor dust lead level, and 14% had an elevated interior window dust lead level. Children in households with 2 to 3 elevated environmental lead samples were more likely to have BLLs of 5 µg/dL or more. A spatial relationship between household proximity to historic lead-emitting facilities and child BLL was not identified. CONCLUSION: Entryway floor dust lead levels were strongly associated with blood lead levels in participants. Results underscore the importance to make housing lead safe by addressing all lead hazards in and around the home. Reduction of child lead exposure is crucial, and continued blood lead surveillance, testing, and inspection of homes of children with BLLs of 5 µg/dL or more to identify and control lead sources are recommended. Pediatric health care providers can be especially vigilant screening Medicaid-eligible/enrolled children and children living in very old housing.

Using Medicaid Data to Improve Childhood Lead Poisoning Prevention Program Outcomes and Blood Lead Surveillance.

CONTEXT: Wisconsin-specific data revealed that not all Medicaid providers were testing children appropriately for blood lead levels and not all blood lead tests were reported to the Department of Health Services, Childhood Lead Poisoning Prevention Program. The Medicaid program requires blood lead screening for all Medicaid-enrolled children at specific ages. Wisconsin state law requires reporting of all blood lead test results. Projects were implemented to encourage appropriate testing for Medicaid-enrolled children and improve blood lead surveillance. METHODS: Medicaid billing data were linked to blood lead data to identify Medicaid-enrolled children who had not received the required tests. Medicaid provider report cards were distributed annually from 2006 to 2011 to inform providers of their compliance with federal testing requirements and of the names of children within their practice who had not been tested. Blood lead tests billed to Medicaid but not in the blood lead database were identified and billing providers were contacted to obtain the test report. RESULTS: The number of children tested increased from 81 834 children per year in 2006 to 106 003 children per year in 2010. Testing of Medicaid-enrolled children increased by 31% from 2006 to 2010. The percentage of Medicaid-enrolled children receiving an age-appropriate test increased from 46% in 2004 to a high of 55% in 2010. There were 9035 blood lead tests identified in the Medicaid billing data that had not been reported from 2007 to 2015. There were 468 billing providers who had unreported tests. All sites with unreported tests were contacted, 84% of test results were obtained, and 14% of test records could not be retrieved. Outpatient clinics accounted for the majority of all unreported tests (72%) and irretrievable test records (74%). DISCUSSION: Childhood lead poisoning prevention programs can effectively utilize Medicaid data to increase testing and improve blood lead surveillance. Primary health care providers should ensure that Medicaid-enrolled children in their care receive the age-appropriate tests. Many Wisconsin health care providers lack awareness of blood lead test reporting requirements. Outpatient clinics account for the largest proportion of unreported tests and highest priority should be given working with these sites to improve reporting practices.

Childhood Lead Poisoning: A Perpetual Environmental Justice Issue?

As the amount of lead in the environment has significantly decreased with the removal of lead in gasoline and paint, the United States has made great strides in preventing lead poisoning or reducing levels of lead in young children's blood. Even so, lead exposure is not equal for all children-low-income and minority children continue to bear a disproportionate burden of exposure primarily through contact with deteriorating lead-based paint from older housing and potentially through drinking contaminated water resulting from failing leaded pipes, as evidenced by the recent events in Flint, Michigan. These facts suggest that childhood lead poisoning is an environmental justice issue worthy of public health consideration and action; "environmental justice" is focused on identifying and addressing disproportionately high and adverse effects of environmental hazards on low-income and minority communities. The question remains, however, as to whether addressing the quality-of-life "risk" factors associated with lead poisoning might eventually lead to reduction in exposure, as well as potentially resulting in adverse health effects. Utilizing an environmental justice framework and examining this issue through a multidimensional environmental justice lens, we contemplated the quality-of-life factors that may essentially predispose minority children and their families to lead poisoning. Specifically, we examined American Community Survey data (2012-2016) focused on comparing race/ethnicity with other sociodemographic variables known to be associated with risks for childhood lead poisoning. The results provide thought-provoking context for making progress toward eliminating lead poisoning as a major environmental justice concern.

Identifying and Chronicling Childhood Lead Poisoning Prevention Program Achievements With "Success Stories".

Success stories showcase a public health program's progress toward achieving population health objectives. The Centers for Disease Control and Prevention's (CDC's) Childhood Lead Poisoning Prevention Program (CLPPP) develops "success stories" in partnership with state and local cooperative agreement recipients as one way to highlight lead poisoning prevention achievements. Success stories can be used to inform policy makers, stakeholders, and the general public. Over time, the process for collecting and developing CLPPP "successes" has evolved. Early efforts to collect success stories from funded recipients resulted in broad or unfocused reports that diminished the program's perceived impact. CDC's CLPPP revised the approach to success story development in order to better articulate the context, intervention or activity, and results related to programs' successes. The new approach results in stronger products ensuring that both CDC and program recipients can use the success stories to demonstrate achievement of key program objectives. We describe how success stories can be used to identify, chronicle, and mobilize public health program achievements using the example of lead poisoning prevention. Success stories allow programs to increase mission awareness, build stakeholder support, generate community interest, and collectively demonstrate progress toward meeting national program objectives.

Lead Exposure in Low and Middle-Income Countries: Perspectives and Lessons on Patterns, Injustices, Economics, and Politics.

Lead exposure is a legacy issue that continues to affect vulnerable population groups globally, but particularly in low and middle-income countries (LMICS). We take a multi-disciplinary approach to examine the patterns of lead exposure in these countries, discuss the underlying injustices and socio-political causes, and the economic costs that are associated with exposure. We conclude with some lessons we drew from our discussion of lead across the disciplines and advocate for a number of approaches to solving this ongoing issue. These include (i) biomonitoring that could be integrated into existing health surveys or public health programs targeting young children; (ii) greater civic engagement to push for solutions; and, (iii) environmental control policies that represent a continuum of local, context-specific to broad, national-level, and even global approaches.

WIC Participation and Blood Lead Levels among Children 1-5 Years: 2007-2014.

BACKGROUND: The CDC recommends a targeted strategy for childhood blood lead screening based on participation in federal programs, such as Medicaid and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Yet, there is scarcity of data on blood lead levels (BLLs) among WIC participants. OBJECTIVE: Our objective was to investigate whether children participating in WIC and not enrolled in Medicaid, who have not been targeted in the historical Medicaid-focused screening strategy, have higher BLLs than children in neither of these programs. METHODS: The analysis included 3,180 children 1-5 y of age in the National Health and Nutrition Examination Surveys conducted in 2007-2014. Log-binomial regression, which allows direct estimation of prevalence ratios, was used to examine associations between WIC participation (in conjunction with Medicaid enrollment) and having BLLs ≥5 µg/dL with adjustment for age (1-2 vs. 3-5 y). RESULTS: The percentage of children participating in "WIC only," "Medicaid only," "both WIC and Medicaid," and "neither" were 18.9%, 10.8%, 25.4%, and 44.9%, respectively. "WIC only," "Medicaid only," and "both WIC and Medicaid" children were more likely to have BLLs ≥5 µg/dL than children who were not enrolled in either program, with adjusted prevalence ratios of 3.29 [95% confidence interval (CI): 1.19, 9.09], 4.56 (95% CI: 2.18, 9.55), and 2.58 (95% CI: 1.18, 5.63). CONCLUSIONS: Children participating in WIC but not Medicaid were more likely to have BLLs ≥5 µg/dL than children who were not enrolled in either program. These findings may inform public health recommendations and clinical practice guidelines. https://doi.org/10.1289/EHP2384